Co-morbidity of substance use disorder and psychopathology in women who use methamphetamine during pregnancy in the US and New Zealand
Introduction
Methamphetamine (MA) abuse continues to be the fastest growing illicit drug problem worldwide (United Nations Office on Drugs and Crime, 2004, United Nations Office on Drugs and Crime, 2007, United Nations Office on Drugs and Crime, 2010, United Nations Office on Drugs and Crime, 2011). The most recent UNODC World Drug Report (United Nations Office on Drugs and Crime, 2011) emphasized the substantial increases in MA use across East Asia and an increase in MA initiation in the United States (US). Oceania is the region with the highest prevalence of amphetamine-type substance (ATS) use, with Australia and New Zealand (NZ) having the highest annual estimates of 2.7% and 2.1%, respectively. One major indication of the health risks of ATS is the increased proportion of women requiring comprehensive health and mental health services in both the US and internationally (Jones et al., 2011, Wechsberg et al., 2010, Wright et al., 2012).
MA is one of the most potent of the ATS. Repeated MA use, higher doses, the onset of MA use at an earlier age and being female have all been associated with increased risk for psychosis and persistent psychiatric symptoms (Chen et al., 2003, Cohen et al., 2007, Hall et al., 1996, McKetin et al., 2006, Nelson-Zlupko et al., 1995, Sekine et al., 2001). In addition, MA use in combination with alcohol and marijuana has been associated with significantly higher symptom scores on depression, obsessiveness, paranoia, and psychoticism than the use of MA alone (Christian et al., 2007).
Evidence that MA is being abused during pregnancy comes from the Treatment Episode Data set that captures admissions to US federally funded treatment centers (Terplan et al., 2009). Admissions for pregnant women using MA increased from 8% in 1994 to 23.7% in 2006. During this period, an increase in co-occurring psychiatric disorders was noted among MA-using women admitted for treatment. Increases were also noted in the proportion in dependent-living situations and those with criminal justice involvement. The Substance Abuse and Mental Health Services (SAMSHA) report (Substance Abuse and Mental Health Services Administration, 2008) found 5.1% of pregnant women aged 15–44 years used illicit drugs during their pregnancy and a further study of a non-clinical population found approximately 5.2% of women reported using MA at least once during their pregnancy (Arria et al., 2006).
While little is known about the co-morbidity of substance use disorders (SUDs) and psychopathology among women who use MA during pregnancy, increased psychosocial problems and polydrug use are common in the often, chaotic lifestyles of women who are drug dependent (Benningfield et al., 2010, Della Grotta et al., 2009, Good et al., 2010, Oei et al., 2010, Wouldes and Woodward, 2010). Of particular concern is the evidence that links maternal psychopathology, drug dependence and other psychosocial problems with negative parenting behaviours and poor developmental outcomes for children (Hans et al., 1999, Wan and Green, 2009). Thus, understanding co-morbidity between SUD and psychiatric disorders among women who use MA during pregnancy is a clinically important issue. From a research perspective, one must disentangle the direction of these associations and the extent to which they are reflective of confounding by other drug use or lifestyle factors.
In 2007, Derauf et al. reported a number of adverse psychosocial circumstances surrounding women who used MA during pregnancy from early results of the US Infant Development, Environment and Lifestyle (IDEAL) Study. Most notable was the finding that the odds of a mother who used MA during pregnancy developing a SUD was 12 times that of mothers in the comparison group. However, no association between prenatal MA use and co-morbid psychiatric disorders was observed.
The present investigation will extend the earlier findings from the US IDEAL Study in a larger combined sample of US and NZ biological mothers. In addition, it will provide an opportunity to determine whether these findings generalize to another culture where there is no legal mandate to report mothers to child protective services (CPS) for illicit drug use during pregnancy, where perinatal care is available at no cost and economic assistance provides a variety of monetary benefits for substance dependent mothers. Exploring these differences will improve our understanding of maternal substance use, the psychosocial issues surrounding mothers who continue to use MA during their pregnancy, and the factors that are associated with co-morbid psychopathology and SUDs.
The specific aims of this investigation were: (1) to describe and compare the psychosocial characteristics of women who use MA during pregnancy in the US and NZ; (2) to examine the associations between prenatal MA use and the probabilities of a SUD and a psychiatric disorder in the US and NZ, holding constant other drug use and lower socioeconomic status (SES); (3) to evaluate the risk of co-morbid SUD and psychiatric disorders in US and NZ mothers.
Section snippets
Study design
Recruitment for the US study took place post-partum in seven hospitals at four sites in the US (Los Angeles, CA; Honolulu, HI; Tulsa, OK; and Des Moines, IA). Meconium specimens were collected from all infants for analysis of drug metabolites. Institutional Review Boards at all participating sites in the US approved the study. A NIDA Certificate of Confidentiality was obtained to ensure confidentiality was maintained for information regarding participants’ drug use, superseding mandatory
Maternal demographics and characteristics
As a result of the matching protocol there were no significant differences between groups in self-identified ethnicity or adequate level of education in either NZ or the US. The predominant ethnicity reported in both the US (40%) and NZ (52%) sample was white (Table 1). Across the US and NZ, mothers in the MA group were more likely to have low SES, live in a single parent household and more likely to present for their first prenatal visit later in pregnancy than comparison mothers. In the US,
Discussion
Despite the distinct differences between the US and NZ health, legal and welfare systems in relation to maternal drug use, MA use during pregnancy was associated with the abuse of alcohol and other drugs and a complex array of family, social, relationship, legal, and psychiatric problems. These findings support and reinforce earlier findings from the US-IDEAL Study (Derauf et al., 2007) as well as other research that has shown that women who use drugs during pregnancy have lifestyles that are
Conclusion
Despite the above limitations, our study provides the first prospective evidence that MA use during pregnancy across two different cultures and in a diverse range of ethnicities is associated with a complex array of difficult social circumstances, psychiatric problems and multiple SUDs. Moreover, this is the first evidence that a significant proportion of mothers who used MA in combination with alcohol during pregnancy were at a heightened risk for co-morbidity of SUD and a positive diagnosis
Role of funding source
This work is part of the US and NZ Infant Development, Environment and Lifestyle Study funded by NIH grants: National Institutes on Drug Abuse, 2RO1DA014948 and RO1DA021757. NIH and/or NIDA had no further role in study design; in the collection, analysis and interpretation of date; in the writing of the manuscript; or in the decision to submit the paper for publication.
Contributors
Dr. Trecia Wouldes wrote the first draft of the manuscript. All authors are responsible for the reported research and have participated in the concept and design, analysis and interpretation of data, drafting or revising of the manuscript. In addition, all authors have approved the manuscript as submitted.
Conflict of interest
None of the authors have a financial association with any product associated with this research or other conflict of interest. There were no commercial sponsors involved in the above matters. There was no honorarium, grant, or other form of payment given to anyone to produce this manuscript.
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